Why PSI Uses Social Marketing:
The Evidence Base
Population Services International
March 2011
Contents
1. Why PSI uses social marketing............................................................................................... 4 What is social marketing? ....................................................................................................... 4 PSI’S approach to social marketing ....................................................................................... 4 Five reasons PSI uses social marketing in developing countries ........................................... 5 2. Malaria .................................................................................................................................... 7 3. HIV/AIDS and Other Sexually Transmitted Infections ............................................................ 12 4. Family Planning ........................................................................................................................ 17 5. Maternal & Child Health .......................................................................................................... 18 6. Conclusion ................................................................................................................................ 20 2
Introduction
This document presents an evidence base for social marketing by highlighting the success of
social marketing projects in improving the health of poor and vulnerable populations around the
world. It is divided into four main sections by health area:
1. Malaria – covering the social marketing of insecticidal bed nets, artemisinin-based
combination therapy, and rapid diagnostic tests;
2. HIV and other sexually transmitted diseases – covering the social marketing of condoms,
counseling and testing services, and adult male circumcision;
3. Family planning and reproductive health – covering the social marketing of modern
contraceptives;
4. Child health – covering the social marketing of water treatment products, oral rehydration
solution, and pre-packaged pneumonia treatment kits.
Each section cites examples from articles published in peer-reviewed journals. The document
demonstrates the success of social marketing in reaching target audiences, increasing access to
health services, developing markets for health products, and changing cultural norms and health
behaviors. Subsections highlight key social marketing efforts and country-specific examples of
effectiveness from peer-reviewed literature.
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1. Why PSI uses social marketing
What is social marketing?
Social marketing is the use of commercial marketing concepts to plan and implement programs
designed to bring about social change (Social Marketing Institute, 2011). The introduction and
promotion of information, products, and services that lead to improved health has benefits for
many segments of society, but particularly those at the base of the economic pyramid that lack
access to health services, either because of where they live or because of the cost of services
(Lefebvre, 2008). For these people, social marketing with its targeted messages, local
distribution networks, and subsidized or free products and services is well-suited to improving
the health situation of poor and underserved populations in developing countries.
The social marketing “product” is not necessarily a physical offering (Weinreich, 2000). It
ranges from tangible products (condoms and malaria treatment kits), to services (voluntary
counseling and testing for HIV) and practices (water treatment and storage), to intangible
products (knowledge of ways HIV is transmitted). Social marketing encourages people to change
their behavior in ways that will bring about direct improvements to their lives, and ultimately
benefit society as a whole.
The origins of social marketing in international health can be traced to India in the 1960s when
the government began promoting family planning, particularly the use of condoms. Thereafter,
social marketing was adopted by family planning programs in developing countries around the
world. When the AIDS pandemic was first recognized in the early 1980s, social marketing was a
ready-made tool for the distribution of condoms to prevent the transmission of HIV and
behavior change messages to promote safer sex (abstinence, fidelity, and limiting the number of
sexual partners) (Lefebvre, 2008). Since then, the role of social marketing and its applications in
international health have expanded, and it is used extensively by organizations such as
Population Services International, the Futures Group, the Academy for Educational
Development, Marie Stopes International, Family Health International, and the Johns Hopkins
Center for Communications Programs. Additionally, local organizations in Africa, Asia, and
Latin America have successfully integrated social marketing into their health programs.
PSI’S approach to social marketing
PSI’s mission is to measurably improve the health of poor and vulnerable people in the
developing world through the implementation of country-specific social marketing projects. PSI
distributes affordable, accessible, and attractive health products in more than 65 countries. PSI
raises awareness of health problems and, through innovative and culturally sensitive
communications, generates demand for life-saving health products and services. PSI’s projects
cover four main health areas: malaria, HIV/AIDS and other STIs, family planning, and maternal
and child health (diarrheal disease, micronutrient deficiencies and acute respiratory infection).
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Through its projects in 2010 alone, PSI saved 17 million years of life that would have otherwise
been lost to death or illness.1 This translates to averting: an estimated 177,000 HIV infections,
more than 20,000 maternal deaths, more than 4 million unintended pregnancies, nearly 40
million malaria episodes, nearly 309,000 malaria deaths, over 6.7 million diarrhea cases, and
over 11,000 diarrhea deaths. In 2010, PSI procured, promoted and distributed more than:
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13.7 million units of safe water solution;
93.3 million water treatment tablets;
4.7 million units of oral re-hydration therapy;
1 billion male condoms;
38.3 million cycles of oral contraception;
7.1 million injectable contraceptives;
2.9 million emergency contraception pills;
26.8 million insecticide-treated malaria nets; and
2.0 million iron fortified tablets.
Five reasons PSI uses social marketing in developing countries
1. Social marketing reaches target audiences directly.
The PSI platform in a country coordinates with government agencies and local organizations to
identify the target audience and plan the scope and structure of the social marketing project.
Then, working with members of the target audience, PSI develops messages that will form the
core themes of the project. To resonate with the target audience, the messages are prepared in the
local language and designed to be both culturally appropriate and content specific. Channels of
communication are selected that will gain the greatest attention. Information can be delivered
through many channels, with radio and TV being the most common. However, interpersonal
communication, street theater, and presentations at community gatherings are important,
particularly in countries where access to mass media is limited. Even populations with low
literacy and education levels can access messages presented in well-placed advertisements, and
product-use information can be presented graphically to ensure comprehension. Target audiences
are considered carefully. For example, in societies where husbands commonly make the
decisions about the reproductive health care received by their wives, messages about family
planning, antenatal care and delivery can be effective if targeted to husbands as well as or rather
than wives.
2. Social marketing increases accessibility of products and services.
Social marketing introduces new distribution networks designed to reach vulnerable and remote
populations while simultaneously strengthening existing networks. PSI social marketing
campaigns and outreach efforts bring the benefits of life-saving products such as ACT for
treatment of malaria and ORS for treatment of diarrhea to people who previously did not have
ready access to health products and services. Through entrepreneurship and franchising, these
1
PSI uses the disability-adjusted life year (DALY) to measure the impact of social marketing programs (i.e. DALYs averted). A DALY is
equivalent to a year of healthy life lost due to death or illness.
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new distribution networks become a permanent part of the health system, thereby improving the
standard of living of the population.
3. Social marketing contributes to the growth of markets.
In addition to their main goal – measurably improving the health status of target populations
through the marketing and distribution of products and services – PSI social marketing projects
also function as pilot projects, stimulating the wider economy to offer similar health-related
products and services. Well-designed social marketing campaigns create markets and
opportunities for private sector employment and entrepreneurship. Social marketing has the role
of providing health-related goods and services to poor and vulnerable populations through
expanded markets. The campaigns increase demand for goods and services, thereby growing the
market.
4. Social marketing influences cultural norms.
While not a direct focus of social marketing, cultural norms – the beliefs and practices, rules, and
expectations of behavior that characterize a social group – can be influenced by social marketing
projects. Contraceptive social marketing, for example, promotes the use of modern contraceptive
methods to space and limit births, which offers a new cultural reality in societies where women
traditionally expected to have no control over the size of their family. Likewise, education
campaigns that emphasize such things as: 1) the need for pregnant women and young children in
malaria-endemic areas to sleep under mosquito nets, 2) the importance of household access to
safe drinking water and adequate sanitation facilities, and 3) the importance of consistent use of
condoms with multiple sexual partners, while encouraging new healthy behaviors, also
inevitably affect cultural norms concerning the social structure of households, division of labor,
interpersonal relations, and financial decision-making. Encouraging healthy behaviors and
increased access to health-related products and services is the goal of PSI social marketing
projects, but the cultural norms that shape individual behavior need careful consideration in the
process.
5. Social marketing changes health behaviors.
The goal of social marketing is the adoption of healthy behaviors by the target population.
Through behavior change communication and the distribution of life-saving products and clinical
services, social marketing projects encourage changes in behavior that will result in permanent
improvements in the health situation of individuals and the target population. Many social
marketing projects have brought about major changes in health behaviors of poor and vulnerable
populations in developing countries; examples include those promoting family planning,
antenatal and delivery care, personal hygiene/sanitation, and the use of condoms to prevent
transmission of HIV. The uptake of new health behaviors promoted by PSI social marketing
projects demonstrates the effectiveness of the behavior change communication messages as well
as the desire of people to improve their own health and that of their family.
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2. Malaria
PSI is a leader in the worldwide effort to control malaria. It supports the implementation of
malaria prevention and treatment programs in developing countries through public and private
sector projects at both the local and national level. Malaria communications campaigns
emphasize the importance of correct and consistent use of insecticide-treated nets (particularly
by pregnant women and young children), prompt diagnosis of malaria symptoms, and treatment
compliance when malaria is confirmed.
Malaria social marketing projects typically focus on two areas:
• Insecticide-treated bed nets – Distribution of insecticide-treated bed nets (ITNs) for
nighttime protection from mosquitoes carrying Plasmodium falciparum. Households
with pregnant women and young children are particularly targeted for net
distributions because women and children are more vulnerable to anemia caused by
malaria.
• Malaria diagnosis and treatment – Distribution of prepackaged doses of
artemisinin-based combination therapies (ACT) for treatment of malaria at the
household level.
PSI is the largest distributor of insecticide-treated nets in the world. Through 2010, PSI has
delivered more than 100 million insecticide-treated nets and long-lasting insecticidal nets and 38
million malaria treatment packets in more than 30 countries around the world. PSI estimates that
64 percent of the lives saved through use of PSI-distributed bed nets and pre-packed treatment
are the result of the distribution of free products.
Insecticide-treated Nets and Long-lasting Insecticidal Nets
Over the past decade, increased funding for malaria control efforts, particularly in Africa, has
resulted in substantial scaling-up of the distribution of insecticide-treated nets (ITNs) and longlasting insecticidal nets through health campaigns and direct delivery (Spiers, 2010). In its
comprehensive World Malaria Report 2010, the World Health Organization (WHO) estimated
that in mid-2010, “42% of households in Africa owned at least one ITN, and 35% of children
slept under an ITN” (World Health Organization, 2010). At the same time, however, WHO noted
that the lifespan of long-lasting insecticidal nets is only three years, which means that the nets
distributed prior to 2008 are due to be replaced. According to WHO, “failure to replace these
nets could lead to a resurgence of malaria cases and deaths” (WHO, 2010).
:: Afghanistan
Social marketing of ITNs was used in Afghanistan to determine whether bed nets are a viable
public health solution to the problem of malaria (Plasmodium falciparum infection) spread by
mosquitoes (Rowland et al., 2002). Communities were given the opportunity to buy the nets;
then they were monitored to determine population coverage and health impact. ITNs were
purchased by 59% of families, effectively growing a market for bed nets. Cross-sectional surveys
showed a 59% reduction in Plasmodium falciparum infection among ITN users, compared with
non-users.
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:: Benin, Kenya, Malawi, Zambia
In February 2000, USAID funded district-wide integrated malaria control projects in Kenya,
Zambia, Malawi and Benin to address ongoing malaria transmission. The projects used social
marketing to distribute insecticide-treated bed nets, which improved access to the nets (Holtz et
al., 2002). Survey results after 15 months of the social marketing program found high knowledge
and recognition of the bed net. Measurable health benefits included lower rates of both malaria
parasitemia and fever, and higher mean hemoglobin in children under five in households who
bought and used the products.
:: Central African Republic, Zimbabwe, Rwanda
A regional KINET project (see the previous study) achieved good coverage in a large, highly
endemic, rural area, reinforcing positive experiences with social marketing of ITNs in the
Central African Republic, Zimbabwe, and Rwanda, by improving accessibility. After the
campaign, the percentage of households with at least one net rose from 37% at the end of 1996 to
52% in mid-1998 (Schellenberg, 1999).
:: Kenya
While the benefits of sleeping under ITNs in malaria-endemic areas are well known, there has
been little research on the impact of this practice on child survival. Between 2004 and 2006, ITN
coverage in Kenya increased from 7% to 67% as a result of a combined approach using social
marketing followed by free distribution of ITNs. During this period, a longitudinal study was
carried out in rural Kenya on a dynamic cohort of 3,500 children age 1 to 59 months. After
adjusting for age, time period, and a number of other variables, the study found that ITN use was
associated with a 44% reduction in mortality, which corresponds to about seven deaths averted
per 1000 ITNs distributed (Fegan et al., 2007).
:: Madagascar
The goal of the PSI/Madagascar malaria prevention program was to reduce morbidity and
mortality among pregnant women and children under five years by increasing the availability
and use of ITNs. The marketing of ITNs through campaigns resulted in marked increases in
ownership and use of ITNs over time, as more users had access to nets. The survey conducted in
2008 showed that 86% of households owned at least one ITN compared with 40% in 2006 – an
increase of 115% over two years. There were also marked changes in the behavior as a result of
the campaigns, as the benefits of using ITNs became widely known. Survey results showed that
the proportion of pregnant women who slept under an ITN increased by 115%, from 27% in
2006 to 58% in 2008 (Raharinjatovo, 2009).
:: Malawi
The cost-effectiveness of insecticide-treated nets (ITNs) was demonstrated in a retrospective
study in Malawi (Stevens et al., 2005). Over a five-year period, 1.5 million ITNs were sold in
Malawi, with the cost per treated-net-year dropping from $7.69 to $3.44. The study results
suggested that a high level of ITN coverage can be achieved through the combined strategy of
targeting vulnerable groups with social marketing campaigns and subsidizing the cost of ITNs
sold through the commercial sector and the public health sector.
:: Namibia
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The Social Marketing Association (SMA), PSI’s local affiliate in Namibia, conducted household
surveys in 2006 and 2009 in three regions of Namibia to determine levels of ownership and use
of insecticide-treated nets (ITNs) in households with pregnant women and/or children under five.
The goal was to increase the use of commercial, NGO, public sector, and socially marketed ITNs
in Namibia. The survey results indicate that net ownership (any type of net) rose substantially
from 56% to 70%, and 85% of households with a net owned an ITN. Net usage increased from
43% to 57% generally, and from 35% to 42% among pregnant women and/or children under
five. Knowledge that malaria is transmitted by mosquitoes increased from 41% to 78%. Overall,
the results support the effectiveness of the SMA malaria prevention and behavior change
communications campaigns (Wolmarans and Akinyemi, 2009).
:: Tanzania
A large-scale social marketing program in Tanzania proved effective in increasing access to
ITNs (Schellenberg et al., 2001). Within three years of implementation of the program, changes
in behavior resulted in more than half of all infants sleeping under ITNs, up from 18% in 1999.
The results of another social marketing program in Tanzania (Abdulla et al., 2001), which
distributed ITNs to children under two years of age with malaria and anemia, showed rapid and
substantial reduction in the prevalence of parasitemia and anemia. Most of the changes occurred
in the first year of the study, with 80% of children sleeping under a net. The ITN social
marketing programs contributed to improved health outcomes in the communities.
:: Tanzania
The question has arisen whether nets distributed free of charge will be maintained (i.e., retreated)
by households that receive them. A study in northeast Tanzania compared usage and condition of
nets in a town and 15 villages where nets and insecticide had to be purchased, with usage and
condition of nets in 24 other villages where more than 15,000 nets were distributed free and
annual retreatment was available free (Maxwell et al., 2006). The results showed that net
coverage of the town population was very high – 93% of the households had at least one net – and
27% of nets had been treated with insecticide. In the 15 villages, an average of 17% of the
population was using a net, and inspections indicated that just 51% of the nets were intact, and
only 11% had been treated. Thus, the proportion of the population actually protected by nets in
the 15 villages was 9%. In the 24 villages where nets and retreatment were provided free of
charge, 92% of nets were still in use or had been brought for retreatment at the time of the study.
The high rate of continued net use and net care in the 24 villages may also have been partly
related to annual visits by a retreatment supervisor. The results of the study suggest that the
social marketing program implemented in the town and 15 villages worked well in the town,
where people could afford to pay for the nets and insecticide, but worked poorly in the villages
where people were less able to afford the nets and their ongoing care. Second, results suggested
that with some monitoring, people who are provided nets free of charge take care of them and
bring them for retreatment.
:: Tanzania
Equity of access to ITNs is a matter of concern in many developing countries where low-income
populations cannot afford to buy mosquito nets directly. A three-year study in rural Tanzania
found that social marketing was effective in increasing access to ITNs in all socio-economic
quintiles, but more so in households in the lowest quintile (Nathan et al., 2004). In 1997, about
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20% of households in the lowest quintile owned a mosquito net compared with over 60% of
households in the highest quintile. Three years later, these figures had increased to more than
half of households in the lowest quintile compared with over 90% of households in the highest
quintile. The increased equity of access can be seen in the ratio of net ownership between the two
quintiles, which increased from 0.3 to 0.6 between 1997 and 2000 (Nathan et al., 2004).
:: Tanzania
A study examining the cost effectiveness of social marketing as a strategy for distributing ITNs
for malaria control in Tanzania compared the social marketing of ITNs in two districts
(Kilombero and Ulanga) with the unassisted sale of ITNs through the commercial sector in a
control district (Kilosa). The Kilombero and Ulanga Insecticide-Treated Net Project (KINET)
used social marketing to stimulate the development of a market for ITNs in the two intervention
districts. The results showed that social marketing was more expensive per ITN distributed than
the unassisted sale of nets through the commercial sector but higher overall coverage was
achieved in the social marketing districts, along with higher coverage among the poor, pregnant
women, and children under five (Kikumbih et al., 2005).
:: Zambia
An evaluation of an ITN social marketing project initiated in three rural districts of Eastern
Province, Zambia looked at the effects of the project on inequities of knowledge, access,
ownership, and use of ITNs (Agha et al., 2007). Public clinics and village volunteers were used
to promote and distribute the subsidized ITNs. A total of 2,986 respondents were interviewed
and grouped according to four socioeconomic (SES) categories: low, medium-low, medium, and
high. The results of the social marketing project showed that while use of ITNs remained low
overall, knowledge, access, ownership, and use of ITNs was higher among respondents exposed
to the social marketing project than those who were not. The results of the SES analysis showed
that there was a decline in SES inequity due to increased access to nets among respondents in the
low SES group. However, the largest increase in net ownership and use of nets occurred among
respondents in the medium and high SES groups. These groups had a disproportionately greater
increase in access to nets compared with low and medium-low groups. The findings suggest that
increased access to nets among the poorest respondents may not lead to increases in net use
unless the price of nets is no longer a barrier to their purchase.
Malaria Diagnosis and Treatment
The World Health Organization now recommends that “all cases of suspected malaria be
confirmed with a diagnostic test prior to treatment” (World Health Organization, 2010). This
ensures that nonmalarial fevers do not get treated as malaria. Ensuring prompt and appropriate
treatment with an artemisinin-based combination therapy also prevents the development of
resistance to artemisinin, which has been fueled by over-the-counter sales of artemisinin
monotherapy in many countries.
:: Cambodia
A cross-sectional study in three remote areas of Cambodia looked at the effect of the policy shift
from artemisinin monotherapies to artemisinin-based combination therapies (ACT) in light of
different delivery strategies. The study found that 78% of artemisinin treatment continues to be
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monotherapy (provided mainly by village vendors and private health workers). At the same time,
however, ACT distributed through the social marketing program (artesunate and mefloquine
[A&M]) has had considerable impact in the area where trained village malaria workers (VMW)
diagnose malaria cases and distribute the malaria treatment. For the most recent episode of fever,
64% of respondents in the VMW area were treated with A&M, compared with 22% in the area
covered by the malaria outreach teams, and 8% in the control area. The study suggests that the
social marketing strategy of providing free malaria diagnosis and ACT by means of trained
village malaria workers is an effective way of dealing with treatment of malaria in remote
malaria-endemic areas (Yeung et al., 2008).
:: Tanzania
Between 2004 and 2008, the ACCESS program to improve access to prompt and effective
malaria treatment implemented a social marketing campaign in rural Tanzania (Ifakara) to
improve malaria treatment awareness and treatment-seeking behavior. The results of the
campaign were documented by surveys in 2004, 2006, and 2008 (Alba et al., 2010). To increase
access to malaria treatment through the private retail sector, a new type of outlet, the accredited
drug dispensing outlet (ADDO), was created in 2006. In the following year, the country switched
the first-line treatment for malaria from sulphadoxine-pyrimethamine (SP) to artemetherlumefantrine (ALu), and subsidized ALu was made available to both health facilities and
ADDOs.
The survey results indicate that between 2004 and 2008, understanding of the causes of malaria
increased from 62% to 84%; health facility attendance as the first treatment option among
patients older than five years increased from 27% to 52%; treatment with antimalarials increased
from 86% to 96%; and timely use of antimalarials (within 24 hours) increased from 80% to 9397%. The availability of drug outlets (health facilities or drug shops) was found to be the most
important determinant of whether patients receive prompt and effective treatment; affordability
and accessibility contribute to a lesser extent. The results of the study suggest that the integrated
approach used by the ACCESS program is effective in improving both understanding of malaria
and treatment-seeking behavior.
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3. HIV/AIDS and Other Sexually Transmitted Infections
PSI implements innovative HIV prevention programs in more than 60 countries in Latin
America, Asia, Africa, and Eastern Europe. Projects include the distribution of male and female
condoms, lubricants, and sterile injecting equipment, and the provision of male circumcision,
HIV counseling and testing, and treatment services for sexually transmitted diseases. Products
are offered at a variety of price points to reach individuals at all income levels, including free
distribution for those who cannot pay. PSI also implements communication interventions that
utilize interpersonal communication and mass media to inform and empower populations at
increased risk of contracting HIV to make healthy decisions, including reducing concurrent
sexual partnerships, undergoing male circumcision for HIV prevention, and reducing risky
behaviors among injecting drug users and men who have sex with men.
Media Campaigns to Increase Knowledge and Change Behavior
Social marketing media campaigns target subgroups of the population with messages about HIV
prevention and treatment. They are particularly useful in reaching hard-to-reach groups such as
young people, men who have sex with men, and injecting drug users with information about how
to avoid contracting the HIV virus. The distribution of free condoms may be part of these
campaigns.
:: Côte d’Ivoire
PSI’s AIDS prevention social marketing program in Côte d’Ivoire targeted men and women at
high risk of contracting HIV and of a low socioeconomic status, within an intervention area
where SIDA dans la Cite, a popular television series on AIDS, was televised (Shapiro and
Meekers, 2000). Even in rural locations that had electricity, reach was very high. Sixty-nine
percent of the study sample knew about the program and 65% had seen at least one episode.
Viewers watched seven episodes on average, indicating that the audience was reached repeatedly
and thus experienced reinforcement of key campaign messages. Analyses showed that after
controlling for other factors, women who had seen 10 or more episodes were 1.4 times more
likely than non-viewers to have used a condom in their last sexual encounter. Men who had seen
10 or more episodes were 2.7 times more likely to have used a condom during their last sexual
encounter.
:: Ethiopia
An HIV/AIDS radio campaign in Addis Abba, Ethiopia was effective in reaching its target
audience. The 26-week radio drama called Journey of Life provided education and modeling for
modern family planning methods, the dangers of HIV/AIDS, and methods of disease avoidance.
The program highly influenced behavioral change. The study found that 79% of households who
listened to the radio at least once a week could correctly recall specific storylines and messages
from the broadcast (Farr, Witte, Jarato, and Menard, 2005).
:: Malawi
The BRIDGE project in Malawi was implemented as a national media campaign to address the
problem of HIV/AIDS. Radio Diaries was created as part of the Bridge campaign because radio
is the most widely used media in Malawi. The program featured HIV-positive men and women
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openly discussing day-to-day events in their lives with the goal of reducing stigma against people
living with HIV (PLWHA) in the population. Data on attitudes toward PLWHA were collected
in a baseline household survey in 2004, and again at mid-term in 2006 (Rimal and Creel, 2008).
The mid-term survey included additional questions to measure exposure to Radio Diaries.
Overall, 62% of respondents reported hearing about the program and of those who listened to the
program more than 50% reported listening to more than two programs. A multivariate analysis of
the relationship between exposure to Radio Diaries and stigma determined that the program did
not have a main effect on stigma, but there was a significant interaction between exposure to the
program and efficacy to reduce number of sexual partners. At the same time, the results of the
campaign showed that knowledge of HIV/AIDS was almost always associated with lower levels
of stigma: the multivariate analysis found that lower education and lack of knowledge of
HIV/AIDS are associated with stronger beliefs that people living with HIV should be isolated
from other people.
:: Nepal, Brazil, and Senegal
In 2002, MTV aired a global media campaign, Staying Alive, to promote HIV prevention among
young people age 16 to 25. The project’s positive impact on young people’s beliefs about HIV
prevention points to the potential of such global campaigns in reaching this important group at
minimal cost. Critics of the MTV campaign said that it would reach only a small elite group of
young people, but MTV made all campaign media materials available free to non-MTV
broadcasters.
Ultimately, an estimated 789 million households in more than 166 countries had access to the
HIV prevention campaign (Geary et al, 2007a; Geary et al, 2007b). Exposure of young people
age 16 to 25 to the campaign was estimated using data from household surveys carried out in
three cities: Kathmandu, Nepal; São Paulo, Brazil, and Dakar, Senegal. The exposure rates were
12% in Kathmandu (32,000), 23% in São Paulo (400,000), and 82% in Dakar (220,000). While
young people with greater resources and online access had higher rates of exposure, in most
countries, they were not the majority. An evaluation showed a consistent positive effect of
exposure to the campaign on interpersonal communication and HIV prevention beliefs. This type
of campaign has the potential to reach young people globally with health messages and have an
impact on social norms.
:: Nigeria
The VISION project was implemented in targeted areas of Nigeria to increase awareness of
HIV/AIDS and to promote HIV/AIDS prevention through behavior change. The project used a
mass media campaign including educational materials and public service announcements to carry
out its activities. Weekly radio programs in target areas disseminated family planning,
HIV/AIDS, and other health information to the general public.
Adults living in the VISION project areas were interviewed in household surveys in 2002 and
2004 (Keating, Meekers, and Adewuyi, 2006). A two-stage logistic regression was used to
analyze the effect of program exposure on 1) discussion of HIV/AIDS with a partner, 2)
awareness that consistent condom use reduces HIV risk, and 3) condom use at last intercourse.
The results of the analysis indicated that exposure to the VISION mass media campaign was
high: 59% for at least one radio advertisement, 47% for at least one printed advertisement, and
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24% for at least one TV program about reproductive health. Differences in the outcome variables
between 2002 baseline data and the 2004 follow-up data were small; however, persons with high
program exposure were one and a half times (O.R. = 1.47, C.I. 1.01-2.16) more likely than those
with no exposure to have discussed HIV/AIDS with a partner. Those with high program
exposure were more than twice as likely (O.R. = 2.20, C.I. 1.49-3.25) as those with low exposure
to know that condom use can reduce the risk of contracting HIV. However, program exposure
had no effect on condom use at last sex.
:: South Africa
The Soul City series, a prime-time television and radio drama transmitted through public
broadcast in South Africa, centered on stories that conveyed AIDS-related messages about HIV
prevention, discrimination against people living with AIDS, and teenage sexuality (Goldstein et
al, 2005). The Soul City 4 intervention was successful: exposure to the campaign was
significantly associated with positive individual and community knowledge, attitudes and
behaviors relating to prevention of HIV infection, gender attitudes, caring and supporting people
affected by AIDS, and taking steps to make changes to stem the epidemic.
Condom Social Marketing
:: India
A large-scale condom social marketing campaign targeted areas in India where female sex
workers were present. Lot quality assurance sampling was used to assess geographical coverage
and quality of condom coverage in the target areas of four states and along selected national
highways (Piot et al., 2010). The study, which was part of Avahan, the India AIDS initiative,
included an estimated 200,000 sex workers and their clients. The results showed that between
2005 and 2008 there was a substantial increase in condom availability in the target areas, with
coverage increasing from 36% to 79%. An extensive network of pharmacies and nontraditional
outlets contributed to the high coverage rates, while traditional outlets provided the bulk of the
condoms purchased.
:: Kenya
PSI/Kenya’s branded and generic mass media campaigns were combined with interpersonal
communication to promote condom use for HIV prevention and make condoms widely available
through the commercial sector (Agha, 2003). The Kenyan government strategy for fighting
HIV/AIDS included providing free air-time to PSI/Kenya for HIV prevention radio broadcasts.
The air-time was used to supplement PSI/Kenya’s ongoing branded communications campaign.
Results of the study revealed that exposure to PSI’s ads was associated with higher perceptions
of personal risk, self-efficacy in using condoms, improved belief about the efficacy of condoms,
condom availability, risk severity and lower levels of embarrassment in purchase of condoms.
In 2007, a PSI/Kenya study assessed whether PSI’s generic mass media campaign dubbed ongea
(to talk) was effective in influencing condom use among youth aged 15 to 24. Condom use at last
sex with casual partners increased significantly among males during the project life from 54.2%
to 68.7% (Seday, 2007).
:: Mozambique
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The JeitO condom social marketing project aimed to increase condom use among men and
women at elevated risk of HIV infection in urban Mozambique. The project’s behavior-change
communications and condom distribution were effective in encouraging safer sex practices
among individuals engaged in sex with non-regular partners. Increased condom use among men
and women in Sofala and Manica provinces was shown to be associated with high level of
exposure to the condom social marketing program (Agha, Karlyn, and Meekers, 2001).
PSI’s targeted radio campaign in Mozambique (1997-1998) promoted behavior change for the
preventions of STIs and HIV/AIDS. PSI began social marketing of JeitO brand condoms in 1995
(Karlyn, 2001), and interpersonal communications activities, including peer-education debates
and street theater, complemented the mass media campaign. Exposure to the radio campaign has
contributed to individual intent to change sexual behavior: 97.2% reported intent to change
compared to 62.8% who were not exposed to the campaign.
:: Uganda
Condom social marketing in Uganda began in 1989 after sharp increases in HIV infection.
Uganda received millions of condoms from international donors, but there remained a variety of
fears and misconceptions about condoms. In 1991 the media began to dispel myths about
condoms and to encourage their use, using condom marketing advertisements in the country’s
primary newspaper. The social marketing of condoms increased, helping normalize their use
(Kirby, 2008).
:: Zambia
A condom social marketing was used as an AIDS prevention strategy in Lusaka, Zambia (Agha,
1998). In 1992, PSI marketed inexpensive condoms, Maximum, in partnership with the
Pharmaceutical Society of Zambia, making condoms widely available and promoting their use
through mass media advertising and peer education campaigns. A survey of the target audience
revealed a significant association between exposure to the program and condom use at last
intercourse for both men and women.
:: Zimbabwe
PSI effectively implemented a social marketing program in Zimbabwe (Meekers, 2001).
Beginning in 1996 the SMP distributed subsidized Protector Plus condoms and promoted their
use through an extensive mass media advertising and promotion campaign. Following the mass
media campaign sales increased to 8.9 million in 1999 from 1.9 million in 1996. The use of
social marketing condoms in sexual contacts with casual partners was consistent (55.6%) during
the six-week study period.
Peer Education
:: Botswana
Social marketing to promote healthy sexual behavior change has also proven to be effective. The
Peer Education HIV/AIDS Prevention Program had a measurable positive impact the workplace
in Botswana in the key areas of improving knowledge, attitudes, and practices related to risky
15
sexual behavior, with the expectation of reducing the incidence of transmission of HIV/AIDS
and other STDs in the long-term (Hope, 2003).
:: Botswana, Cameroon, Guinea, South Africa
A quasi-experimental design was used (Agha, 2002) to evaluate the impact of adolescent sexual
health interventions conducted by PSI social marketing programs in Cameroon, Botswana, South
Africa and Guinea in 1994-1998. Findings demonstrated that when adolescents are exposed to
substantial levels of intervention including mass media and interpersonal communication in a
context where contraceptives are available, such as through the intervention and through a
national social marketing program, their attitudes and behavior related to preventive sexual
health behavior improve. Young men and women in Cameroon became more aware of the
benefits of sexual protection, experienced a reduction in barriers to safer sex and an increase in
self-efficacy. Young women reported a lower likelihood of having had sex by age 15 and young
men reported fewer sexual partners.
The Cameroon program was able to reach a substantial proportion of the population through
mass media and interpersonal communication, and resulted in increased condom use and greater
rates of abstinence. Among young women in Botswana, the program had a positive impact on
perceived susceptibility to sexual risk, perceived benefits of prevention and perceived barriers to
safer sex.
:: China
Social marketing projects are a staple of global AIDS prevention efforts (Agha, 2003) because
they have been shown to increase condom usage among populations at risk. A study in Chengdu,
China was the first to explore how to use participatory communication to promote safer sexual
behavior among gay men and men who have sex with men in the area (Gao and Wang, 2007).
Key findings showed that the peer-based participatory communication strategy was effective in
encouraging condom use with casual sex partners in the intervention group.
Another social marketing program in China successfully promoted safe injection norms and
increased access to clean needles over a 12-month period among injecting drug users. The
incidence of hepatitis C virus was significantly lower in the intervention site than in the control
sites among new injectors (Wu, et al., 2007).
:: India
A 2006 PSI study funded by evaluated the effect of the Integrated Behavior Change
Communication (iBCC) component of the 5-year Operation Lighthouse project, an HIV
prevention program targeting truckers and other high-risk males in India. Exposure to the iBCC
activities was associated with increases reported in condom use at last sex (Sharma and
Todankar, 2006).
:: Russia
A 2008 study by PSI assessed exposure to PSI programming among men who have sex with men
(MSM) in eight regions of the Russian Federation where PSI implemented a Global Fund-funded
project targeting MSM. The social marketing intervention, LaSky, combined the distribution of
16
informational and motivational materials with outreach activities and other interpersonal
communications delivered by trained peer educators. Evaluation analysis revealed that PSI
program exposure was associated with an increase in condom use with casual and commercial
partners, as well as a greater likelihood of being tested for STIs (Sergeyev and Gorbachev,
2008).
STD Diagnosis and Treatment
:: Uganda
In 1995 there was an initiative to introduce and evaluate over-the-counter social marketing in
private pharmacies, drug shops and private clinics of a treatment kit for urethral discharge in men
in Uganda. The Clear Seven kit experienced higher cure rate (84% vs. 47%) and treatment
compliance (93% vs. 87%). Users of the treatment kit also had higher condom use during
treatment (36% vs. 18%) than controls. At the end of the study it was recommended for
expanded distribution in sub-Saharan Africa (Jacobs, et al., 2003).
4. Family Planning
PSI has launched reproductive health programs in over 30 countries throughout the world, and in
2009 alone, PSI prevented more than 4 million unwanted pregnancies, averted over 20,000
maternal deaths and gave millions of couples the skills and tools necessary to achieve their ideal
family size. PSI’s behavior change communication (BCC) strategies are tailored to target
populations and adapted to local socio-cultural norms, educational contexts and economic
realities. PSI’s reproductive health portfolio includes many methods of family planning as well
as the prevention of maternal death through programs targeting post-partum hemorrhage and
sepsis. PSI is actively working to better integrate its reproductive health and HIV programs to
offer more comprehensive, client-friendly services and information.
:: Cameroon
The effectiveness of targeted social marketing to promote adolescent and young adult
reproductive health was assessed in urban Cameroon (Van Rossem and Meekers, 2000). PSI and
PMSC Horizon Jeunes targeted adolescents through peer education, youth clubs, mass media
promotion, and behavior change communications. After more than a year of implementation,
knowledge of the program was nearly universal and the majority of youths had direct contact
with the program. There was a significant increase in reported use of family planning methods,
including condoms.
:: Indonesia
A social marketing intervention was designed to reduce maternal mortality by involving
husbands in pregnancy and child birth (Shefner-Rogers, Sood, 2004). The intervention, called
the Suami SIAGA (I’m an Alert Husband) campaign, was targeted at men to encourage them to
be involved in their wives’ antenatal care and plan for any emergencies. The campaign relied on
mass media (including radio, television and print), promotional materials and interpersonal
communication to convey messages about safe motherhood to men. Results showed that the
intervention was effective in conveying the intended messages to men who were exposed to the
17
campaign. Depending on the type of media that men were exposed to, from 57.2% – 60.8% of
survey respondents indicated that they had acquired new knowledge from the campaign.
:: Pakistan
The Green Star social franchise network was launched in order to increase the access of lowincome women to quality family planning services. This study was developed in order to
measure the quality of the care provided by the franchise clinics (Gulzar et al 2008). Clinic staff
were observed and patients were requested to fill out questionnaires regarding their satisfaction
with the services they were provided. The results of the survey indicated that overall Green Star
clinics were well-stocked with family planning methods, clients were given accurate information
regarding contraception, and 86% of clinic attendees indicated that they were given their chosen
method. Clinic staffers were determined to be generally competent and had the ability to provide
correct information. This study demonstrates that social franchising can be an effective way of
reaching low-income women with high-quality services.
:: South Africa
A PSI study used a targeted social marketing program on reproductive health beliefs and
behavior among young women in Soweto, South Africa. The program was effective in increasing
young women’s awareness of the risk of pregnancy, and knowledge that condoms are effective
for pregnancy and HIV/AIDS prevention, and that other contraceptives are effective for
pregnancy prevention. In response to adolescents’ concerns, the intervention was developed with
a focus on pregnancy prevention. Findings indicate that the intervention also increased the
percentage of women who had used condoms and percentage of women who had discussions
about contraception (Meekers, 2000).
5. Maternal & Child Health
:: Bolivia
An intervention was undertaken to encourage low-income women to use a socially-marketed
vitamin supplement, VitalDia (Warnick et al, 2004). The intervention was successful in raising
awareness and increasing use of vitamin supplements. In the final survey, 61% of participants
had heard of supplements compared to 37% at baseline. Additionally, 11% of women
participating in the baseline survey had ever used a supplement, compared to 25% of women in
final survey. At follow-up, it was determined that 11% of survey participants had used VitalDia.
:: Cambodia
An intervention was developed to increase use of a socially-marketed weekly iron-folic acid
supplement in order to combat anemia in women of reproductive age (Kanal et al, 2005). The
product name (“Kolap Krahorm”) branding was developed with the input of Cambodian women
in the target demographics. The supplement was marketed using billboards, informational
materials, songs and free promotional materials. The three targeted groups, school girls, female
factory workers and rural women, were also exposed to peer education programs. At the sixmonth follow-up survey, all groups reported greater knowledge of the causes of anemia and the
benefits of the supplements than at baseline. In a companion paper (Crape et al 2005), it was
determined that the number of women with anemia had decreased in all target groups, indicating
18
use of a supplement. However, women of higher socioeconomic means were more likely to have
decreased levels of anemia compared to women of lower socioeconomic status.
:: China
In order to combat iron deficiency in Guizhou province, women were encouraged via a social
marketing campaign to use an iron-fortified soy sauce, FeSS (Sun et al, 2007). FeSS was
promoted via a mass-media campaign, consisting of newspaper ads and television public service
announcements, free product giveaways promoting FeSS, and educational opportunities such as
health lectures. Intervention groups reported significantly higher awareness of the causes of
anemia as well as awareness and use of FeSS.
:: Philippines
An intervention was conducted in Pangasinan province with the aim of encouraging the uptake
of an iron-folic acid supplement (Paulino, 2005). The supplement was named Femina and was
promoted in a variety of ways including collaboration with local officials, free promotional
materials and prizes, trainings and educational programs. The supplement was sold in
drugstores, by village health workers and in schools. By the end of the study, knowledge of the
correct and recommended use of iron supplements had increased and sales of Femina were
strong, especially at pharmacies.
:: Vietnam
In Hai Duong province, an intervention was undertaken to promote the use of iron-folic acid
supplements in women of reproductive age (Berger et al, 2005). Pregnant women were able to
obtain the supplement for free while non-pregnant women were encouraged to buy the
supplement. The supplement was packaged to be attractive to women and distributed through
partners from local Women’s Unions. In non-pregnant women, at a follow up visit one year after
the intervention began, anemia had dropped from 45.6% to 19.1%. For pregnant women in the
first trimester, 40% were anemic at baseline. At the one year mark, only 8.7% pregnant women
in the first trimester were anemic.
:: Vietnam
An intervention was designed to increase the uptake of iron-folic acid supplements in women via
a social marketing campaign (Khan et al, 2005). In order to improve the image of the
supplements, new packaging was designed and a mass-media campaign was initiated to promote
the product. Pregnant women were given the supplement for free, while women who were not
pregnant were encouraged to purchase the supplements. Community health workers and
members of the local government and women’s network were included in planning the
implementation of the intervention and received training about the importance of preventing
anemia. At the year survey, knowledge of the causes and effects of anemia had greatly
increased. Moreover, the number of pregnant and non-pregnant women using supplements also
increased, demonstrating that the social marketing campaign influenced ideas and practices.
19
6. Conclusion
This wide variety of findings shows that social marketing is a viable tool to reach communities
with information, promote access to products and services, and create changes in knowledge,
attitudes, and behaviors across various health areas. After four decades in practice, social
marketing programs, including PSI’s, have improved the lives of impoverished populations all
over the world. PSI continues to have an impact on health by raising awareness of health issues
and generating demand for quality health products and services through behavior change
communication strategies and social marketing programs that reach target audiences, increase
accessibility, grow markets, change cultural norms, and change health behaviors.
20
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